Abstracts from the British Society of Echocardiography annual meeting 2023

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BSEcho 2023 conference report
It was a great pleasure for the British Society of Echocardiography to host delegates for their annual conference 2023 at the International Conference Centre Wales.The ICC Wales was the perfect venue with a spacious exhibition room and auditorium and quality rooms for the parallel streams all supported by the wonderful Welsh hospitality and catering.The format of delivery was developed from last year with the continuation of the hybrid format which gave all the members the opportunity to engage either through face-to-face or via the online platform with over 1200 delegates attending in total.
The conference was opened by our out-going president, Dr. Claire Colebourn, who provided the perfect starting point and platform for the subsequent enriched content from high quality, expert speakers delivered across parallel sessions.For the first time a track dedicated to congenital heart disease and inherited cardiomyopathies was provided on Friday, and intensivist echocardiography on Saturday.These sessions were sandwiched by an auditorium packed programme and the pre-accreditation/ research and audit sessions.We were delighted to welcome our International speaker, Dr. Judy Hung, who provided us with a fantastic journey of echocardiography from historical perspectives to future directions, and our invited speaker, Prof. Sanjay Sharma, who entertained a full auditorium of keen delegates with his insights into the athletes heart; we were also entranced by the debate on artificial intelligence from the brains and wit of Professors Paul Leeson and Rick Steeds.The educational content was supported by ongoing workshops that provided expertise insight on focused 'hot topics' including: musculoskeletal health, TOE, Stress Echocardiography and Diastolic function (providing practical insight into the earlier delivered proposed new BSE guidelines).These workshops were attended and taught through enthusiasm and interest underpinning the BSE's widening philosophy for education.The exhibition room was a buzz of networking and engagement with the 30 exhibitors providing that important link to industry and service.It was also fantastic to see high quality research provided through posters and oral presentations and we would like to congratulate Eleanor Drew for her excellent study and presentation 'Identification of a three-dimensional transthoracic echocardiography derived correction factor to improve the accuracy of left ventricular outflow tract measurements' with her being a truly worthy recipient of the Investigator of the Year award.Although this year was a resounding success and the echocardiographic community never felt as close, it was delivered shortly after the premature passing of our great echocardiographer and pioneer Professor Mark Monaghan.His life and his character were remembered throughout the conference and a dedicated evening meal was a fitting tribute to him, allowing colleagues to remember Mark and share stories of his life and contributions to the BSE.The Annual General Meeting saw our new president, Prof Dan Augustine take the reins and we were pleased to see him present his memberfocussed pledge that will take our Society onwards and upwards.We are now building and preparing for Edinburgh 2024.We are extremely excited that this will be another huge success and will continue to provide the high-quality education, the diverse content and the excellent space for shared ideas and practice.Until then let's embrace our year in echocardiography.

Background:
The limitations that the left ventricular outflow tract (LVOT) is circular can result in underestimation of LVOT area and subsequently aortic valve area (AVA) when calculated from standard transthoracic echocardiograms (TTE).Three-dimensional (3D) techniques have allowed more precise LVOT measurements, eliminating geometric assumptions associated with two-dimensional (2D) imaging.
Purpose/aims: To determine the feasibility and reproducibility of 3D LVOT measurements.Secondly, to improve accuracy of 2D TTE-based AVA calculation by introducing a correction factor (CF) derived from 3D TTE images and validating this in aortic stenosis (AS) patients.Methods: In this retrospective pilot study patients with any degree of AS had an LVOT diameter (LVOTd) measured from a 2D parasternal long axis image (D1).Additionally, a 3D zoom dataset of the LVOT, and aortic valve was obtained.3D LVOT area planimetry could be performed in 93% of patients, and subsequently converted into a theoretical circle, and a diameter provided (D2).D2/D1 derived the CF.CF validation was via determining the effect on the correlation between AVA and haemodynamic AS parameters.Finally, the ability of the CF to reclassify AS severity was determined.
Results: D1 and D2 were significantly different (P < 0.001) and subsequently a CF of 1.1 was derived.Operator variability of 2D LVOTd was superior to 3D LVOT area planimetry.LVOT area was underestimated when calculated from 2D LVOTd, compared to LVOT area planimetry, with improved agreement upon CF application.Correlation between AVA and peak velocity, mean pressure gradient and velocity ratio was unchanged with the CF.CF application reclassified 2 mild cases (11%) to no AS, 13 moderate cases (33%) as mild and 21 severe cases (39%) were reclassified as moderate.Conclusions: Regarding the feasibility, 1 out of 5 patients could not have LVOT area planimetry performed.This, in addition to the inferior operator variability of 3D measurements, limits the role of 3D imaging and the CF in daily practice.Further research determining the agreement of 3D measurements with the gold standard of computer tomography is required to substantiate routine CF use.

Supporting Figures:
Figure 1  Background: In 2020 the BSE updated the methods and reference values for assessing the proximal ascending aorta (PAA).It is important to quantify how implementing these methods alter the rate of 'dilated' PAAs identified by echocardiography, and how this will impact the wider service and patient pathway.Purpose: To compare the rate of dilated PAAs detected by the current BSE methods, and two other methods of assessing the PAA in our patient population.Methods: All transthoracic echocardiograms where the PAA was measured between January 2018 and December 2019 were included.Studies with incomplete demographics or bicuspid aortic valves were excluded.The PAA was indexed to height (Method 1), body surface area (BSA) (Method 2) and height 2.7 (Method 3), compared to the corresponding normal reference values and classified as 'dilated' or 'nondilated' accordingly.The rate of 'dilated' proximal ascending aortas were compared using Chi-squared test.Results: 11,828 studies were identified.2189 were removed due to incomplete patient demographics and 27 with bicuspid aortic valves.2710 studies were removed as Method 2 does not provide reference values for patients < 45 and Method 3 > 80 years old.6902 studies were included in the analysis.Method 1 classified significantly more PAAs as 'dilated' (31%, AUC = 0.930) compared to Method 2 (10%, AUC = 0.841) and 3 (3%, AUC = 0.921) (X 2 (1, N = 6902) = 2435.8,p < 0.001).Conclusion: BP for the purpose of myocardial work should be consistently recorded in the left lateral decubitus position to minimise the small but significant influence of positional blood pressure variation.Results: All parameters were significantly worse in the final scan of the toxicity group compared with baseline and there was no significant change in the controls (Table 1).Time for pCTRCT was similar between GLS/LArS/LACI and better than EF CTRCT (Table 2).LArS and LACI had significantly higher EF at the point of pCTRCT compared with GLS (Figure 1).Purpose: This audit aimed to evaluate the current compliance of our VHD clinic with European guidelines for the surveillance and management of patients with severe AS.We aimed to determine whether patients were followed up within the guideline-accepted timeframe, whether they received prompt intervention, and assess the impact of COVID-19 on patient's access to the service.Methods: This retrospective, single-centre, observational study identified patients with severe AS assessed in the VHD clinic at the Princess of Wales Hospital between 2017 and 2022.Data collected included appointment dates, time intervals between appointments, referral date for intervention, date and type of intervention, patient status, and date of death.We also compared surveillance and intervention data before and during the COVID-19 pandemic.

Results:
The average time between specialist visits for patients with severe aortic stenosis was 9.7 ± 6.8 months (Figure 1).During the COVID-19 pandemic, the mean follow-up time increased significantly from 6.77 ± 3.77 to 13.52 ± 7.79 months (p < 0.001) (Figure 2).No significant difference in survival was found between patients seen within six months or after six months (p = 0.743).Out of the cohort, 49% of patients (200) were referred for intervention, and the mean waiting time for intervention was 4.95 months ± 4.25 months (range: < 1 to 30.53 months).
Conclusions: This cohort of patients has a very high mortality rate due to severe AS and significant comorbidities in old age and so timing of intervention is crucial for their outcome.This audit found that follow-up of patients with severe AS within the recommended six-month timeframe was challenging, particularly during the COVID-19 pandemic.However, patients who were referred for intervention had shorter referral-tointervention times during the pandemic.We suspect this is due to the improved access to TAVI, reduced inpatient stay and potential exposure of patients to the COVID-19 infection and faster recovery times.Method: Sonographers and physicians across two Cardiorespiratory Departments reported independently on the IVSd, LVIDd, PWd, EF by Simpson's and visually estimated EF of the same 5 anonymised studies.The Two-factor Anova Test, and ICC were calculated for each parameter, and the results reported.
Results: Data were collected from 20 participants (Trust 1 n = 11, Trust 2 n = 9) and the ICC for each parameter recorded (Table 1).Excellent correlation was seen at both sites for assessment of EF with fair (Trust 1) and poor (Trust 2) correlation for the PWd measurement.The assessment of EF was comparable between both trusts (Figures 1, 2).

Conclusion:
The results highlight the inherent variability in echocardiography reporting and demonstrate a method by which this variability can be assessed objectively and be audited.By understanding the ICC within a department, and between departments across the NHS, clinicians can feel confident that reported results are reproducible, irrespective of the performing sonographer.This should form an aspect of QA and clinical governance that ensures consistent access to guideline-directed therapy.Background: Patient satisfaction is a critical indicator of the quality of healthcare services.The National Health Service face challenges with waiting times and backlogs.Echocardiography plays a pivotal role in the management of cardiac conditions.Understanding patient experience is essential in improving patient-centred care.This cross-sectional study assessed the degree of patient satisfaction and its relationship with modifiable and non-modifiable factors.
Method: Patients (n = 54) attending a busy district general hospital for their first echocardiogram were recruited.They were asked to complete a survey which included variables relevant to patient satisfaction (e.g., demographics, self-perceived health, discomfort during the echocardiogram, expectation regarding healthcare services, physical environment, clinical competence, accessibility and waiting time).Descriptive statistics and linear regression analysis was performed to assess the associations between these factors and overall patient satisfaction.
Results: Patients reported high satisfaction for the following: overall experience of having an echocardiogram; sonographers interpersonal care/communication, information provision, clinical competence; accessibility and waiting time on the day.Moderate satisfactions were reported for the physical environment of the hospital.Two modifiable factors and two non-modifiable factors were found to be associated with overall satisfaction towards echocardiography.These were interpersonal communication, information provision, self-perceived health and discomfort.

Conclusion:
Overall, generally patients were satisfied with their experience.Understanding modifiable and non-modifiable factors for individual centres may help to enhance patients' experience and healthcare quality.
Results: 673 focussed scans on 29 days over a 6-month period were performed.74% needed no further follow-up.A substantial burden of varied functional and structural pathology was diagnosed and triaged to further imaging and clinics (Figs. 1, 2).All 161 pilot scans were SOP-compliant, with 81% exceeding that minimum standard.There were no adverse outcomes at 9 months that a full scan would have prevented (Fig. 3).FECs halved the mean waiting time to 3 months.Patient feedback was excellent, with no complaints from GPs or hospital colleagues.

Conclusion:
A FEC model can effectively facilitate timely diagnoses and management of serious cardiac pathology with good mediumterm safety.This proof-of-concept may help resource-limited departments to address rising demand whilst keeping patient safety central.Results: Data was collected for 7504 participants across 30 NHS Trusts as part of Group 1/2 and a further 6,277 across 34 NHS Trusts as part of Group 3. In overall cohort comparison of Group 1/2 vs Group 3 (Table 1), number of non-smokers (49.5% vs 53.6%), prevalence of hypertension (48.4% vs 52.9%), hypercholesterolaemia (39.9% vs 47.4%), diabetes (19.9% vs 22.7%), and family history of premature CAD (6.8% vs 33.7%) was higher in Group 3, while previous percutaneous coronary intervention was lower (32.5% vs 21.0%) (all p < 0.001).Exercise SE (30.5% vs 37.4%), and use of contrast enhancement (71.9% vs 83.6%) was more common in Group 3, but use of Atropine in Dobutamine SE was lower (49.4% vs 44.3%) (all p < 0.001).These results are further broken into positive and negative SE result in Tables 2 and 3 respectively.

Conclusion:
This study provides evidence of potential effects from recent clinical guideline changes and subsequent clinical practice as well as the changing landscape of patients being referred for SE.Background: Three-dimensional (3D) transthoracic echocardiography (TTE) allows for the quantification of left ventricular (LV) structure, function and myocardial strain.The clinical adoption of this technology requires demonstration of best-case, real-world (repeated acquisition) reproducibility.In view of this, the aim of the current study was to determine the intra-and inter-observer reproducibility of 3D derived LV structural, functional and myocardial strain parameters in young healthy volunteers.Methods: Thirteen healthy controls (24 ± 3 years; n = 6 male; n = 7 female) were recruited (see Table 1).Participants were required to attend two separate visits to the laboratory (3-5 days apart at the same time of day; see Figure 1).A single sonographer acquired and analysed a 3D TTE on both visits (intra-observer).A second sonographer acquired and analysed a further 3D TTE on the first visit (inter-observer).Participant height, body mass, blood pressure and an electrocardiogram were recorded at each visit.LV volumes, mass, ejection fraction, global longitudinal, radial, circumferential, area strain and twist were measured.Reproducibility was assessed using a Paired T-Test, intraclass correlation coefficients (ICC) and coefficients of variation (CoV).
Results: There was no evidence of systematic bias as determined by paired T-tests for any parameter.Intra-and inter-observer reproducibility of 3D structure and function was generally "moderate" to "excellent" (ICC 0.45-0.95and 0.40-0.81respectively) with relatively small CoV (4-14% and 6-14% respectively; see Table 2).Sphericity index demonstrated "poor" intra-and inter-observer reproducibility (ICC − 0.13 and − 0.10 respectively) with relatively large CoV (16% and 18% respectively).Intra-and inter-observer reproducibility of 3D myocardial strain parameters were generally "moderate" to "good" (ICC 0.50-0.60 and 0.48-0.78respectively) with relatively small CoV (7-10% and 6-9% respectively).Twist demonstrated "poor" intra-observer and "moderate" inter-observer reproducibility (ICC 0.35 and 0.48 respectively) with relatively large CoV (50% and 35% respectively).Conclusion: 3D TTE derived structure, function and myocardial strain demonstrates good intra-and inter-observer reproducibility in a best-case setting i.e., young healthy individuals.This is with exception of sphericity index and twist which demonstrated consistently low reproducibility.Our findings, along with the recognised benefits of 3D TTE, suggest there is potential for the adoption of this technology in regular clinical imaging.However, evidence of 3D TTE reproducibility needs to be replicated in larger more diverse and diseased populations.Furthermore, the standardisation of 3D TTE acquisition and analysis is essential for safe adoption of this technology in clinical practice.

Figure 1 (
Figure 1 (abstract ABS004) A comparison of number of ProximalAscending Aortas classified as dilated using three different methods of normalising and assessing the proximal ascending aorta to body size; Method 1-height and sex, Method 2-body surface area, age and sex and Method 3-height 2.7 , age and sex.*Significantly different from Method 1 (p < 0.001).**Significantly different to Method 2 (p < 0.001) The clock is ticking: an innovative echocardiogram efficiency improvement programme at Guy's & St Thomas' NHS Trust vs national picture Dario Freitas 1, † , Jenna Smith 1, † , Camelia Demetrescu 1 , Nathan Proudlove 2 1 Guy's and St Thomas' Hospital, NHS Trust, London, UK; 2 The University of Manchester, UK Echo Research & Practice 2024, 11(Suppl 1):ABS006 † Joint first authors.Background: Echocardiography (TTE) is one of the most requested non-invasive cardiac diagnostic tests in the NHS with demand often exceeding capacity.This is reflected in the national dataset, where post-pandemic data show around 45% of TTE outpatients wait longer than the 6-week NHS England target of 1% set in 2008, compared with 7% pre-pandemic.These national data show Guys & St Thomas' (GSTT) performance was 30% breaching in February 2022 (Figure1).Whilst there is no equivalent national dataset for inpatient TTE, many trusts, including GSTT, experience similar challenges despite robust triaging and the BSE's TTE timeframe guidelines.Purpose: To understand GSTT TTE performance and apply innovative quality improvement (QI) methodologies to inpatient and outpatient pathways to improve service efficiency and reduce waiting times.Methods: Several change ideas were designed, tested & refined through plan-do-study-act (PDSA) cycles (Figures2, 3).Results: Around 20 outpatient appointments per week are no longer wasted (increase in activity of over 1000 TTEs per year) with a significant reduction in 6-week waiting-time breaches to below 5%.Inpatient TTE service efficiency improved from 73 to 88% of referrals performed within 1-day or less.Levels of staffing and number of TTE referrals consistently stayed the same throughout the QI project.Conclusions: Clinical Scientists leading rigorous QI initiatives can significantly improve TTE service efficiency in the post-pandemic era despite national workforce shortages and with no additional resources.Other ongoing elements of our QI programme include work on reducing DNA rates, inappropriate TTE referrals and maintaining TTE service efficiency despite major IT changes in the trust.

Figure 1 (
Figure 1 (abstract ABS006) National diagnostic set data.Each line is the performance of an NHS trust (N = 134) on the 6-week-wait benchmark as a % of the Echocardiography waiting list (top) and the number of patients (bottom)

Figure 1 ( 1 St
Figure 1 (abstract ABS008) EF at scan where parameter indicates cardiotoxicity.EF criteria: absolute value drop by > 10% to value below 50%.GLS criteria: relative drop of > 15%.LArS criteria: relative drop of > 15%.LACI criteria: Relative increase of > 10%.T-Test significance analysis shown Conclusion: Novel measures of left atrial function and left atrioventricular coupling can diagnose pCTRCT at significantly higher EF than GLS.Left atrial function and left atrioventricular coupling are possible markers of pCTRCT, potentially enabling alterations in cardioprotective and cancer management at an earlier stage than if EF was used alone.Prospective studies utilising LArS and LACI are needed.

Figure 1 (
Figure 1 (abstract ABS010) Average follow up time of patients with severe aortic stenosis.Dashed line represents the guideline recommended follow up time (6 months)

Background:
Echocardiography remains the workhorse of cardiac imaging, and reproducibility of results within departments and across sites is key to consistent decision-making for patients.The Intraclass Correlation Coefficient (ICC) allows objective assessment of the variation in reporting of the same study by sonographers both within the same department and also across different locations.An ICC of > 0.75 represents excellent correlation.Purpose: To audit the Inter-observer variability (IOV) of left ventricular size and functional assessment in and between two hospital Trusts.

Figure 1 (
Figure 1 (abstract ABS012) Graph demonstrating standard error of the mean for the visual assessment of Left Ventricular Ejection Fraction In early 2022, staff shortages and post-pandemic pressures in our large DGH led to a backlog of over 1500 outpatient echocardiograms, with an average wait of nearly 6 months.This posed a substantial risk of late or missed diagnosis to our patients.Purpose: A "Focused Echo Clinic" (FEC) model was proposed to facilitate higher scan turnover, timely diagnosis and triage to further management.Methods: A pilot period of 4 days of two parallel FECs with 15 min per scan was executed in April 2022, with immediate audit and internal quality assurance.Pre-defined patient selection criteria and a standard operating procedure (SOP) were developed.All scans were performed by senior Band 7 echocardiographers.Patients not needing follow-up were audited at 9 months for adverse outcomes.

Figure 1 (
Figure 1 (abstract ABS014) April 2022 Pilot Findings and Triage Destinations of patients requiring follow-up after focused echo.PLVC = physiologist-led valve clinic (recommended time-to-clinic displayed to right).SCD = sudden cardiac death

Methods:
Participant demographics and SE procedure details were collected for 13,781 participants as part of the multi-centre BSE-NSTEP study.Data was acquired from March 2015-September 2020 as part of Groups 1 and 2 of the study, and October 2020-May 2023 as Group 3. Comparisons were conducted for the overall cohorts and further according SE result (positive or negative).Descriptive statistics were investigated as frequencies and medians [interquartile range (IQR)].Comparison of discrete data was conducted using Pearson's χ 2 tests.

Figure 1 (
Figure 1 (abstract ABS020) Protocol schematic.Visit 1-observer 1 and 2 acquired and analysed a 3D TTE to assess inter-observer reproducibility.Visit 2-observer 1 acquired and analysed a second 3D TTE to assess intra-observer reproducibility for measurement of global longitudinal strain.BP was recorded seated and in the left lateral decubitus position using a validated automated BP machine.BP was added to mean transvalvular aortic gradient for the calculation of myocardial work before intervention.Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were compared to assess differences attributable to BP variation.Results: Significant increases in GWI (1841 ± 652 mmHg% vs 1782 ± 639 mmHg%, P = 0.005), GCW (2305 ± 728 mmHg% vs 2236 ± 728 mmHg%, P = 0.015) and GWW (263 ± 131 mmHg% vs 255 ± 125 mmHg%, P = 0.019) were observed when using seated BP compared to left lateral decubitus recorded BP.There was no significant difference in any myocardial work parameters due to inter-arm BP variations.
Conclusion:Adopting the 2020 BSE recommended methods significantly increase the detection rate of dilated PAAs in our patient population.This will impact subsequent downstream testing, affecting resource planning and patient journey.ABS005The impact of positional blood pressure variation on myocardial work in patients with severe aortic stenosis Peter Luke 1 , Mohammad Alkhalil 2 , Mario E. Diaz Nuila 2 , Ioakim Spyridopoulos 2,3 , Christopher Eggett 1 Introduction: Myocardial work incorporates myocardial deformation imaging and non-invasive blood pressure (BP) readings.It is well established that BP differs between supine and seated positions and there are reports that inter-arm BP variability exists in some patients with severe aortic stenosis.Purpose: Evaluation of body position differences in BP and consequent effect upon myocardial work is currently unknown.This study aims to assess if BP variation due to body position or inter-arm BP differences significantly alter myocardial work.Method: 43 subjects with severe aortic stenosis scheduled for transcatheter aortic valve intervention were prospectively recruited.Each had an echocardiogram prior to intervention, pre-discharge and at six-week follow-up.Optimised apical four, two and long-axis views were used

Table 1 (abstract ABS012
) Intraclass Correlation Coefficient values for 2D echo measurements To identify temporal changes in the patient demographics of those being investigated with SE and the method of SE practice across NHS Trusts in the UK.

Table 3
pulsed-wave Doppler envelope scored good in 61 studies (52%).Continuous-wave aortic Doppler envelope tracing scored perfect in 64 studies (54%).The two-dimensional parasternal long axis image scored perfect in 108 studies (92%).The apical-three chamber pulsedwave Doppler image scored poor in 108 studies (92%).PEDOFF probe imaging scored poorly in 60 studies (51%).Conclusion: Overall, UHW's assessment of AS is very good.However, there are areas of assessment which do require addressing and may require further teaching and training.

Table 1 (abstract ABS020
) Participant demographics and conventional two-dimensional echocardiography BP: blood pressure

Table 2 (
abstract ABS020) Intra-and inter-observer reproducibility of three-dimensional left ventricular structure, function and myocardial strain